Download MONTHLY STATEMENT OF FAMILY INCOME AND EXPENSES

MONTHLY STATEMENT OF FAMILY INCOME AND EXPENSES
NAME:
Number in Family:
Marital Status:
Budget from:
MONTHLY INCOME
*Proof of income required
Employment income (after deductions)
EI benefits
Social Assistance
Child Tax Benefit + UCCB
Pensions
Spousal or child support income
Rental income
Income Tax Refund
Net Self-employment income
Yours
Spouse/others
*Attach a breakdown showing gross income and expenses
Other income
TOTAL MONTHLY FAMILY INCOME
MONTHLY FAMILY DISCRETIONARY EXPENSES
Housing expenses
Rent/ mortgage
Property Taxes (if not included in mortgage)
Lot Rent
Heating/Gas/Oil/Wood
Electricity
Water
Telephone/Cell
Cable TV/Internet
House Maintenance and Repairs
Personal expenses
Meals eaten outside the home
Tobacco and/or alcohol
Entertainment
Donations
Gifts, holidays, etc.
School and Sport Supplies
Barber & Hairdresser
Bank fees
COMMENTS AND NOTES:
to
NON-DISCRETIONARY EXPENSES
*Receipts or other proof required
Child Support payment
Spousal Support payment
Child Care
Prescriptions (non-recoverable portion)
Court-imposed fines or penalties
Expenses as a condition of employment
TOTAL NON-DISCRETIONARY EXPENSES
MONTHLY FAMILY DISCRETIONARY EXPENSES (continued)
Living expenses
Groceries
Laundry & Dry Cleaning
Clothing
Dental
Transportation expenses
Car lease or payment
Fuel costs
Car Repairs/Maintenance
Public Transportation/Tolls
Insurance Expenses
Vehicle
House/Residential
Life
Medical (private)
Payment to estate (bankruptcy)
Other
TOTAL MONTHLY DISCRETIONARY EXPENSES
SUMMARY OF EXPENSES:
NON-DISCRETIONARY
DISCRETIONARY
OTHER
TOTAL EXPENSES
EXCESS (DEFICIENCY) OF INCOME OVER EXPENSES =
I hereby certify that the above is an accurate statement of my income and expenses as witnessed by my signature and that I am aware of
my obligations to contribute a portion of my surplus income to the estate.
DATE: _______________________________ SIGNATURE: __________________________________________________